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Endovascular treatment of thoracoabdominal
aortic aneurysm: a case report
Arash Mohammadi Tofigh
1*
, Massoud Ghasemi
2
, Babak Heidari Aghdam
2
, Mersedeh Karvandi
3
, Afsoon Kaboli
2
Abstract
Introduction: Thoracoabdominal aortic aneurysms usually present in elderly patients with serious renal, pulmonary,
cerebral, or cardiac comorbidities that pose a great challenge to the attending surgeon. Endovascular techniques
for the treatment of thoracoabdominal aneurysms are not yet widely used due to limitations associated with them,
such as spinal and visceral ischemia.
Case presentation: An 87-year-old Caucasian man with a symptomatic Crawford type I thoracoabdominal aortic
aneurysm was treated successfully with a long tube stent graft using endovascular techniques and without any
complication in follow-up examinations. The stent was placed distal to the left subclavian artery, and proximal to
the celiac axis.
Conclusion: The use of endovascular stents for long segment thoracoabdominal aortic aneurysms needs to
undergo clinical investigation to determine whether this procedure decreases morbidity and mortality rates.
Introduction
Advancements in diagnostic techniques have made the
detection of thoracoabdominal aortic aneurysm feasible,
with most centers reporting an increase of 5% in the
detection of suprarenal aneurysms. Thoracoabdomina l
aortic aneurysms are usually identified in elderly
patients with serious renal, pulmonary, cerebral, or car-

diac comorbidities that pose a great challenge to the
attending surg eon [1]. Surgery neces sitates a thoracoab-
dominal incision that will appro ach the aneurysm
through the retroperitoneum and mobilize the visceral
organs medially. In some cases, the surgeon utilizes car-
diopulmonary bypass to perfuse the distal vessels, hop-
ing to decrease the incidence of paraplegia [2].
The advent of endovascular aortic prosthesis provides
patients with alternativetherapywhichhopesto
decrease the morbidity and mortality of surgery [3].
Endovascular techniques are well described f or abdom-
inal and thoracic aortic aneurysms. These techniques
are quite new as applied to thoracoabdominal aneur-
ysms, however, due to serious adverse events such as
spinal and visceral ischemia following the procedure [4].
We describe in this case report a patient with an
extensive Crawford type I thoracoabdominal aneurysm
treated with the placement of a stent graft in the thor-
acic aorta using endovascular techniques.
Case presentation
An 87-year-old Caucasian man presented to our institu-
tion with chest and epigastric pain radiating to his back.
Computed tomographic scans were performed urgently,
and these showed a large Crawford type I thoracoab-
dominal aortic aneurysm (Figure 1). The aneurysm mea-
sured17cminlengthandwas5cmto6cmdistal
from the left subclavian artery and 2 cm to 3 cm proxi-
mal to the celiac axis. The maximum anteroposterior
diameter of the aneurysm was 13 cm above the dia-
phragm. The aorta between the celiac axis and the renal

arteries was of normal size. Another aneurysm measur-
ing 6 cm in length and 4 cm in diameter with no exten-
sion to the iliac arteries was detected distal to the renal
arteries.
Our patient was not in a fit condition to undergo
open surgery, so endovascular surgery was the preferred
option. The diameters of the proximal and distal necks
of the aneurysm were 3.2 cm and 3.4 cm, and a large
mural thrombosis was present along all its length. We
decidedtotreatourpatientwithasingletubestent
graft. Although a long segment of the aorta would be
* Correspondence:
1
Imam Hossein Medical Center, Shahid Beheshti University of Medical
Sciences, Tehran, Iran
Mohammadi Tofigh et al. Journal of Medical Case Reports 2010, 4:37
/>JOURNAL OF MEDICAL
CASE REPORTS
© 2010 Mohamma di Tofigh et al; licensee BioMed Central Ltd. This is an Open Access article distribute d under the terms of the
Creative Common s Attribution License (http://creat ivecommons.org/licenses/by/2.0), whic h permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly c ited.
Figure 1 Computed tomography scan showing the patient’s Crawford Type I thoracoabdominal aneurysm.
Figure 2 Follow-up computed tomography angiography showing a total exclusion of the aneurysm by the stent graft.
Mohammadi Tofigh et al. Journal of Medical Case Reports 2010, 4:37
/>Page 2 of 4
covered during the procedure, we considered that there
was a low chance of spinal ischemia, as the mural
thrombosis had plugged all of his intercostal and lumbar
arteries. Cerebrospinal fluid drainage was considered as
aprotectivemoveforspinalcirculationduringthe

procedure.
Under general anesthesia, our patient’srightfemoral
artery was dissected and controlled. An endovascular
stent graft (VALIANT TF 4242C200X, Medtronic) was
deployed distal to the left subclavian artery, thus cover-
ing the aneurysm. The stent graft was 21 cm in length
and was placed just above his celiac axis. We controlled
the proximal end deployment by real-time transesopha-
geal echocardiography, and the distal end deployment
under angiography. Follow-up transesophageal echocar-
diography, computed tomography and angiography
showed a complete exclusion of the thoracoabdominal
aneurysm (Figure 2). Correcti on of the abdominal aortic
aneurysm was programmed for later. The patient was
discharged three days after the procedure and showed
no complications during the succeeding nine months.
Discussion
The surgical treatment of thoracoabdominal aneurysms
poses a major challenge to the vascular surgeon, espe-
cially because patients are usually elderly and have ser-
ious comorbidities. The development of endovascular
prostheses has greatly improved the treatment of
patients with aneurysm or dissection in the thoracic and
abdominal aorta [4-6]. This is a major achievement in
the therapy of these types of aneurysms, but it necessi-
tates precise diagnostic investigations to determine the
proximal and distal necks of the a neurysm, the vessels
involved in the aneurysm, and the location of tears in
aortic dissection. One of the major challenges is the risk
of paraplegia in patients who undergo surgical treatment

of these aneurysms. Short cross-clamp time, distal per-
fusion,hypothermia,cerebrospinal fluid drainage and
the use of steroids are s ome of the strategies aimed at
decreasing the risks of surgery [7].
The use of endovascular stents could potentially
decrease the risk of paraplegia and serious morbidities
associated with the surgical approach. Using a long tube
stent graft to exclude the aneurysm is a new approach
to treat thoracoabdominal aortic aneurysms. However,
serious complications like visceral and spinal ischemia
should still be considered before surgery. Graft distor-
tion will be considered as a potential risk in longer stent
grafts and controlling the whole procedure using real-
time angiography and transesophageal echocardiography
is very important to avoid this complication [8]. Chuter
et al. [9] developed a multi-branched stent graft for the
treatment of thoracoabdominal aneurysm that would
decrease the risk of vi scer al ischemia. This device, how-
ever, is still in the experimental phase.
Conclusion
The use of endovascular stents for long segment thora-
coabdominal aortic aneurysms will have to undergo clin-
ical investigation to determine whether the stents
decrease the morbidity or mortality rates associated with
the condition. Although the patient described in this
case report is doing well at nine months, a longer fol-
low-up time is needed to further identify the beneficial
effects of this new approach to a complex problem.
Patient’s perspective
Following the intervention our patient sai d that he had

not believed that his condition would be treated so
easily and he had expected a serious open surgery.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A co py of the written consent is available
for review by the Editor-in-Chief of this journal.
Acknowledgements
We thank the staff of the catheterization laboratory of the Imam Khomeini
Hospital for their valuable assistance to the authors.
Author details
1
Imam Hossein Medical Center, Shahid Beheshti University of Medical
Sciences, Tehran, Iran.
2
Research Center of Endovascular Intervention, Tehran,
Iran.
3
Taleghani Hospital, Shahid Beheshti University of Medical Sciences,
Tehran, Iran.
Authors’ contributions
AMT served as the vascular surgeon to the patient described in this case
report. MG, AK and BHA were the interventionists, while MK was the
echocardiologist. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 29 October 2009
Accepted: 2 February 2010 Published: 2 February 2010
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doi:10.1186/1752-1947-4-37
Cite this article as: Mohammadi Tofigh et al.: Endovascular treatment of
thoracoabdominal aortic aneurysm: a case report. Journal of Medical
Case Reports 2010 4:37.
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